Notification

Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies


Notification Issue Date: 11/27/2019

This version of the policy will become effective 02/09/2020. AIM Specialty Health® (AIM) has revised its Clinical Appropriateness Guidelines for Sleep Disorder Management. These guidelines will become effective 02/09/2020. Upon approval, these guidelines will be available online at: http://aimspecialtyhealth.com/CG-Sleep.html.

The summary changes are as follows:

  • Added chronic narcotic use as a contraindication to APAP.
  • Expanded treatment of mild OSA with APAP and CPAP to patients with any hypertension.


Medicare Advantage Policy

Title:Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies
Policy #:MA07.058h

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

The Company has delegated the responsibility for utilization management activities for the following sleep disorder testing and positive airway pressure therapy services and supplies to AIM Specialty Health® (AIM) with the exception of services performed in the emergency room or during an inpatient or observation unit stay.

For information on policies related to this topic, refer to the Cross References section in this policy.

Please refer to the References section of this policy for a link to applicable LCD, NCD, or the entire AIM Clinical Appropriateness Guidelines for Sleep Disorder Management, that are part of this program, as well as all applicable procedure codes.

AIM first utilizes Medicare guidelines (e.g., Local Coverage Determinations [LCD], National Coverage Determinations [NCD]). If no Medicare guidelines exist, AIM will utilize their AIM Clinical Appropriateness Guidelines for Sleep Disorder Management to determine medical necessity for these services.
  • Facility-based sleep disorder testing and positive airway pressure (PAP) titration
  • Out-of-center sleep disorder testing and PAP titration
  • Positive airway pressure therapy
  • Supplies related to PAP therapy


BILLING REQUIREMENTS

For those specific circumstances where less than six hours of monitoring and recording of PSG are utilized or warranted, specific documentation must be maintained in the individual's record as to why a shortened study was medically necessary. Under these circumstances, the PSG would be billed with the 52 modifier to signify that a "reduced service" was performed and will be reimbursed accordingly.

The performance of multiple nights of out of center sleep testing is considered one study (one unit of service) because it is performed as a single episode of testing. The date of service should be reported as the date the study is completed.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.
Policy Guidelines

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, sleep disorder testing and positive airway pressure therapy services and supplies are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria for the services and supplies are met.

However, services that are identified as not medically necessary or experimental/ investigational are not eligible for coverage or reimbursement by the Company.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The FDA has approved several types of single-level continuous positive airway pressure (CPAP), auto-adjusting positive airway pressure (APAP), and bi-level positive airway pressure (BPAP) for obstructive sleep apnea and/or respiratory insufficiency caused by central and/or mixed apneas and periodic breathing.

Description

The Company has delegated the responsibility for utilization management activities for the following sleep disorder testing and positive airway pressure therapy services and supplies to AIM Specialty Health® (AIM). To determine medical necessity for these services, AIM first utilizes Medicare guidelines (e.g., Local Coverage Determinations (LCD), National Coverage Determinations NCD). If no Medicare guidelines exist, AIM will utilize their Clinical Appropriateness Guidelines for Sleep Disorder Management to direct the application of these services for our members. Multiple sources were used to develop these guidelines, including technology assessments, peer-reviewed medical literature, clinical outcomes research, and consensus opinion in medical practice. The primary resources include:
  • Academy of Sleep Medicine
  • Agency for Healthcare Research and Quality
  • American Academy of Family Physicians
  • American Academy of Otolaryngology—Head and Neck Surgery Foundation
  • American Academy of Pediatrics
  • American College of Physicians
  • American Thoracic society
  • Canadian Agency for Drugs and Technologies in Health

References

AIM Specialty Health®. AIM Clinical Appropriateness Guidelines for Sleep Disorder Management. 2019. [AIM Web site]. 02/09/2020. Available at: http://www.aimspecialtyhealth.com. Accessed 09/09/2019.

Centers for Medicare and Medicaid Services (CMS). Coverage Decision Memorandum for Sleep Testing for Obstructive Sleep Apnea (OSA) 100-3, Change request 6543. [CMS Web site]. 2009. Available at: http://www.cms.gov/transmittals/downloads/R103NCD.pdf. Accessed August 19, 2019.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System.Pub 100-04 Medicare National Coverage Determinations. Transmittal 2679 Revised and Clarified Place of Service (POS) Coding Instructions. [CMS Web site]. 03/29/2013. Available at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2679CP.pdf. Accessed August 19, 2019.

Centers for Medicare & Medicaid Services (CMS). Frequently Asked Questions Related to Change Request 7631 (Revised and Clarified Place of Service Coding Instructions). [CMS Web site]. 04/25/2013. Available at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQs-CR7631-4-25-13.pdf. Accessed August 19, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD).240.4: Continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA). [CMS Web site]. 3/13/2008. Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=226&ncdver=3&DocID=240.4&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&kq=true&SearchType=Advanced&bc=IAAAAAgAAAAAAA%3d%3d&. Accessed August 19, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD).240.4.1: Sleep Testing for Obstructive Sleep Apnea (OSA). [CMS Web site]. 3/3/2009. Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=330&ncdver=1&DocID=240.4.1&kq=true&SearchType=Advanced&bc=IAAAAAgAAAAAAA%3d%3d&. Accessed August 19, 2019.

Centers for Medicare and Medicaid Services (CMS). Pub 100-03 Medicare National Coverage Determinations, Change request 6048. [CMS Web site]. 10/15/2008. Available at: http://www.cms.hhs.gov/Transmittals/Downloads/R96NCD.pdf. Accessed August 19, 2019.

Noridian Healthcare Solutions, LLC. Local Coverage Determination (LCD).L33718: Positive airway pressure (PAP) devices for the treatment of obstructive sleep apnea. [NHIC Web site]. 01/01/2019. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Positive+Airway+Pressure+PAP+Devices+for+the+Treatment+of+Obstructive+Sleep+Apnea+LCD+and+PA. Accessed August 19, 2019.

Noridian Healthcare Solutions, LLC. Local Coverage Determination (LCD). L33800: Respiratory assist devices. [NHIC Web site]. 01/01/2017. Available at: https://med.noridianmedicare.com/documents/2230703/7218263/Respiratory+Assist+Devices+LCD+and+PA/25c966f2-e3e6-4d6d-8d74-d1a3491d257f. Accessed August 19, 2019.

Novitas Solutions. Local Coverage Determination (LCD). L35050: Outpatient Sleep Studies [Novitas Web site]. Original 10/01/2015. Revised: 04/18/2019. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35050&ver=27&Keyword=Outpatient+sleep+studies&KeywordSearchType=Or&Date=&PolicyType=Both&ArticleType=SAD%7cEd&Cntrctr=338*1&KeyWordLookUp=Doc&SearchType=Advanced&CoverageSelection=Both&kq=true&bc=IAAAACAAAAAA&. Accessed August 19, 2019.

Trikalinos TA, Ip S, Raman G, et al. Home diagnosis of obstructive sleep apnea-hypopnea syndrome. AHRQ Technology Assessment Program. [CMS Web site]. 08/08/2007. Available at: http://www.cms.hhs.gov/determinationprocess/downloads/id48TA.pdf. Accessed August 19, 2019.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

95782, 95783, 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

Follow AIM Guidelines for medical necessity


HCPCS Level II Code Number(s)

A4604 Tubing with integrated heating element for use with a positive airway pressure device

A7027 Combination oral/nasal mask, used with continuous positive airway pressure device, each

A7028 Oral cushion for combination oral/nasal mask, replacement only, each

A7029 Nasal pillow for combination oral/nasal mask, replacement only, pair

A7030 Full face mask used with a positive airway pressure device, each

A7031 Face mask interface, replacement for full face mask, each

A7032 Replacement cushion for use on a nasal application device mask interface, replacement only, each

A7033 Pillow for use on a nasal cannula type interface, replacement only, pair

A7034 Nasal interface (mask or cannula type) used with a positive airway pressure device, with or without head strap

A7035 Headgear used with a positive airway pressure device

A7036 Chin strap used with a positive airway pressure device

A7037 Tubing used with a positive airway pressure device

A7038 Filter, disposable, used with a positive airway pressure device

A7039 Filter, nondisposable, used with a positive airway pressure device

A7044 Oral interface used with a positive airway pressure device, each

A7045 Exhalation port with or without swivel used with accessories for positive airway devices, replacement only

A7046 Water chamber for humidifier, used with positive airway pressure device, replacement, only

E0470 Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

E0561 Humidifier, non-heated, used with positive airway pressure device

E0562 Humidifier, heated, used with positive airway pressure device

E0601 Continuous positive airway pressure (CPAP) device

E1399 Durable medical equipment, miscellaneous

G0398 Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation

G0399 Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation

G0400 Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels



Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

MA07.058h
02/09/2020This version of the policy will become effective 02/09/2020. AIM Specialty Health® (AIM) has revised its Clinical Appropriateness Guidelines for Sleep Disorder Management. These guidelines will become effective 02/09/2020. Upon approval, these guidelines will be available online at: http://aimspecialtyhealth.com/CG-Sleep.html.

The summary changes are as follows:
  • Added chronic narcotic use as a contraindication to APAP.
  • Expanded treatment of mild OSA with APAP and CPAP to patients with any hypertension.

MA07.058g
06/29/2019This version of the policy will become effective 06/29/2019. AIM Specialty Health® (AIM) has revised its Clinical Appropriateness Guidelines for Sleep Disorder Management. These guidelines will become effective 06/29/2019. Upon approval, these guidelines will be available online at: http://aimspecialtyhealth.com/CG-Sleep.html.

The summary changes are as follows:
  • Criteria were moved for patients with established CSA and combined under one indication: BPAP with and without back-up rate feature.
  • The condition to try rate support for central sleep apnea to align with clinical practice was removed.

Revisions from MA07.058f:
12/19/2018This policy has been reissued in accordance with the Company's annual review process.
03/01/2018This version of the policy will become effective 03/01/2018.

The following policy has been revised to communicate the Company’s delegation of precertification/preapproval of ouf-of-center sleep disorder testing to AIM Specialty Health® (AIM).

The following CPT code has been removed from this policy:
95803

The following HCPCS code has been removed from this policy:
A9279 Monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified

All ICD-10 CM codes have been removed from this policy.

Revisions from MA07.058e:
11/10/2017This version of the policy will become effective 11/10/2017.

Place of service requirements updated for the following Current Procedure Terminology (CPT) codes: 95800, 95801 or 95806.

Revisions from MA07.058d:
10/14/2016The intent of this policy remains unchanged, but the documentation requirements for continued PAP therapy have been updated.
The following HCPCS code has been added to this policy: A9279.

Revisions from MA07.058c:
10/01/2016ICD-10 CM codes have been added to this policy:

N52.35: Erectile dysfunction following radiation therapy
N52.36: Erectile dysfunction following interstitial seed therapy
N52.37: Erectile dysfunction following prostate ablative therapy

The following ICD-10 CM narrative has been revised in this policy:
N52.39:
FROM: Other post-surgical erectile dysfunction
TO: Other and unspecified postprocedural erectile dysfunction

Revision from MA07.058b:
10/01/2015ICD-10-CM codes have been added and clinically reviewed considering the scope and intent of the policy document and the appropriateness of the codes for the policy.

The following ICD-10 CM codes have been added to this policy:

F10.182F10.282F10.982F19.21F51.01F51.02F51.03F51.09
F51.11F51.12F51.13F51.19F51.3F51.4F51.5F51.8
G47.10G47.11G47.12G47.13G47.14G47.19G47.20G47.21
G47.22G47.23G47.24G47.25G47.26G47.27G47.29G47.30
G47.31G47.32G47.34G47.35G47.36G47.39G47.50 G47.51
G47.54 G47.59 G47.61 G47.69 G47.8 N52.01N52.02N52.03
N52.1N52.2 N52.31N52.32N52.33N52.34N52.39N52.8
N52.9

Revisions from MA07.058a
08/19/2015ICD-10-CM codes have been added and clinically reviewed considering the scope and intent of the policy document and the appropriateness of the codes for the policy.

The following ICD-10 CM codes have been added to this policy:
E66.2 F11.182 F11.282 F11.982 F13.182 F13.282 F13.982 F14.182 F14.282 F14.982 F15.182 F15.282 F15.982 F19.182 F19.282 F19.982 G47.33 G47.411 G47.419 G47.421 G47.429 G47.52 G47.53
2/15/2015The policy was updated to communicate the Company's decision to include precertification/preapproval of positive airway pressure (PAP) therapy and supplies and to delegate precertification/preapproval to AIM.

The title of this policy has been updated to Sleep Disorder Testing and Positive Airway Pressure Therapy. The previous title of this policy was Sleep Disorder Testing.

References to "home-based sleep testing" updated to "out of center sleep testing".

Existing durable medical equipment documentation requirements, in accordance with Medicare, are now included with examples.

Face-to-Face requirements with professional provider for identified items added to policy.

The following HCPCS codes have been added to this policy (all medically necessary):
E0470, E0471, E0561, E0562, E0601, E1399, A4604, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046

The following ICD-9 CM codes have been removed from this policy:
327.30 Circadian rhythm sleep disorder, unspecified
327.31 Circadian rhythm sleep disorder, delayed sleep phase type
327.32 Circadian rhythm sleep disorder, advanced sleep phase type
327.33 Circadian rhythm sleep disorder, irregular sleep-wake type
327.34 Circadian rhythm sleep disorder, free-running type
327.35 Circadian rhythm sleep disorder, jet lag type
327.36 Circadian rhythm sleep disorder, shift work type
327.37 Circadian rhythm sleep disorder in conditions classified elsewhere
327.39 Other circadian rhythm sleep disorder
327.8 Other organic sleep disorders
333.2 Myoclonus
780.54 Hypersomnia, unspecified
786.04 Cheyne-Stokes respiration

MA07.058
01/01/2015This is a new policy.





Version Effective Date: 02/09/2020
Version Issued Date: 02/10/2020
Version Reissued Date: N/A